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When, how and to whom should chief executives speak honestly about the challenges they face? A question that led to animated discussion at a recent New Cavendish Group meeting.

Leaders in the NHS are expected to abide by the Nolan Principles. On the face of it, they provide a clear set of standards that should act as a touchstone for any decision taken by a chief executive.

But chief executives are working in complex environments. How easy is it in practice to stand by the principles if your hospital is under significant operational or financial pressures and you’re being asked to speak out by both staff and media?

Selflessness: holders of public office should act solely in terms of the public interest

Those who think it’s in the public interest to know what’s going on inside hospital walls might say it’s important to highlight the pressures on the NHS – to encourage people to seek alternative help if possible and, in the long term, support arguments for improved funding to the whole system.

A counter-argument might be that those who should be entering the hospital system might be deterred, or that it strengthens arguments about a fundamental rethink on how the NHS is funded.

Chief executives could consider their own version of the IPSO Editors’ Code of Practice, which says that decisions need to “serve, and be proportionate to, the public interest”.

Integrity: holders of public office must avoid placing themselves under any obligation to people or organisations that might try inappropriately to influence them in their work

Much of the discussion at the meeting was around interactions trusts had with national bodies about when and how to engage with the media.

While it was not suggested that speaking out would lead to a direct ‘punishment’, it was felt that national bodies could be risk averse in their judgements about what constituted appropriate media engagement, and that failure to ‘toe the line’ would affect relationships and how individuals and institutions were regarded. This was a particular concern for leaders who were relatively early in their career.

Objectivity: holders of public office must act and take decisions impartially, fairly and on merit – using the best evidence and without discrimination or bias

Many chief executives considering media ‘bids’ were concerned a story would be manipulated to suit an editorial agenda, so that an honest attempt at openness could become a sensational story about threats to patient safety.

According to OfCom, ‘due impartiality’ does not mean equal time has to be given to every view, or that every facet of every argument has to be represented – so chief executives may be right to worry. But on the other hand, those at the meeting gave several examples of balanced reporting that helped trusts (such as on recruitment and retention).

Accountability: holders of public office are accountable for their decisions and actions

In making one organisation or service visible and accountable, we risk downplaying the role of others. Or, perhaps worse, risk passing blame to organisations not present to give their view.

There is another view on accountability, which is that felt by chief executives to their staff. Andrew Foster wrote recently on supporting staff who are under extreme pressure, recognising that “the first thing is to acknowledge the problem and take it seriously”.

Any statement made to a group of several thousand individuals is effectively a public statement. Chief executives will want to ensure their staff feel supported, but should also consider the wider impact of the statements they make.

Openness: information should not be withheld from the public unless there are clear and lawful reasons for doing so

Frankly, when an emergency department is seeing twice as many people as it was designed for – and as more of those people need to be admitted and discharges become more difficult – it’s hard to hide the difficulties from the public.

So the challenge for chief executives may be not so much being open about the problems, but more being clear about how tough it is to fix the problems – which could risk a tension with a leader’s need to give staff a vision and hope for the future.

Honesty: holders of office in public life should be truthful

“How can we talk with credibility about external problems when we know there are still so many things we need to do to get our own houses in order?” asked one chief executive in the group.

External pressures can create a smokescreen behind which we hide and pretend that our own issues are minor in comparison. And dealing with the work they create can take up time and energy that would otherwise be applied to internal improvements.

In reality we know we need to acknowledge both – and good chief executives will hold the mirror up inside their organisation as much as they do to the wider system.

Leadership: holders of office should actively promote and robustly support the principles

As we have seen, it’s not always straightforward in practice when it comes to speaking out in public. Chief executives need to weigh up the pros and cons of how it might impact on their own reputation and ability to lead in future, and on their staff and the patients they serve.

These are not easy decisions, and yet when asked about the support offered to chief executives, the New Cavendish Group meeting was the first time many had been able to voice their thoughts to colleagues.

We suggest three actions that could be considered to support chief executives:

Investing in communications as a strategic function in the NHS. As the recent ‘State of NHS provider communications’ report shows, fewer than half of trust communications leads report directly to the chief executive.

As leaders from both national and local bodies reflect on the lessons from this winter and plans for next year, they should ensure that they include reflections on media engagement.

The most valuable learning is from lived experience, and chief executives should continue to share their learning and experience with each other – whether in local STPs, national networks or any other informal or formal setting.